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Damage to the pituitary stalk will affect labs how

all levels will decrease except prolactin will increase

1

elevated prolactin levels cause amenorrhea because

LH and FSH will decrease

2

prolactin has no stimulatory hormone, it has only

dopamine

3

hypothyroidism will also cause increased prolactin due to

TRH -thyroid releasing hormone- acts on prolactin and TSH

4

signs/symptoms of hyperprolactinemia in female

galactorrhea
amenorrhea
infertility

5

signs/symptoms of hyperprolactinemia in male

impotence
decreased libido
infertility

6

causes of hyperprolactinemia

hypothalamic dz-sarcoid, pituitary stalk dz,pregnancy, hypothyroid, renal failure, pituitary tumors,cirrhosis, acromegaly, idiopathic, drugs,

7

drugs assoc with hyperprolactinemia

phenothiazine, metoclopramide,reserpine,methyldopa,, estrogen, opiates,cocaine, TCA, MAO inhib., verapamil, H2 blockers, SSRI's

8

prolactin level >150 in nonlactating and nonpregnant, think

prolactinoma

9

macroadenoma

>10mm

10

microadenoma

<10mm

11

rule out secondary causes hyperprolactinema by

MRI brain

12

work up suprasellar macroadenoma, infrasellar macroadenomas

visual field testing, eval anterior pituitary function (TSH,ACTH,FSH,LH,IGF1)
infertility or amenorrhea tx with bromocriptine or caberrgoline
if no response to rx, may need surgery

13

treatment of microadenamas

regular menses-no tx
infertility-bromocriptine
amenorrhea- bromo/cabergoline, OR estrogen/progesterone

14

most common cause of acromegaly

GH producing tumor of the pituitary

15

unique sign of acromegaly

enlarging glove and shoe size

16

S/S acromegaly

enlarging shoe and glove size, widened teeth spacing, incr. soft tissue mass palms/soles, macroglossia, hyperhydrosis, prominent jaw, deep voice, hyperglycemia, arthritis

17

best screening lab for acromegaly

IGF-1

18

confirmation of acromegaly diagnosis

failure of growth hormone to suppress <1ug/L within 1-2 hours of 75G oral glucose load

19

tx of acromegaly

surgery for pituitary adenoma, if no remission after surgery, add somatostatin (octreotide) +/- GH receptor antagonist pegvisomant +/- pituitary irradiation

20

complications of acromegaly

sleep apnea, carpal tunnel, CHF, LVH, HTN, cardiomegaly, OA, DM, hyperprolactinemia, hypogonadism, visual field defects , giantism

21

giantism in acromegaly occurs when

GH hyper secretion occurs prior to long bone epiphyseal closure

22

**Surgery indicated in acromegaly for

pituitary adenomas secreting : ACTH,TSH,GH
adenomas assoc with mass effect, vision field defects or hypopituitarism
prolactinomas unresponsive to dopamine agonists

23

20 year old presents with impotence, decreased libido, infertility, and anosmia. Lab: decreased testosterone, LH, FSH
Dx & Tx

Kallman's syndrome-GnRH deficiency
Tx-testosterone

24

causes of GnRH deficiency

Kallman syndrome, mutation in GnRH receptor gene, hyperprolactinemia
acquired deficiency: long distance runners, anorexia nervosa, starvation, stress

25

Prolactin levels must be measured in all patients with....

hypogonadism and low LH/FSH

26

hypopituitarism leads to deficiency of

multiple hormones

27

hypopituitarism in young children see

growth retardation ( decreased growth hormone)

28

hypopituitarism in older children see

delayed puberty (decreased LH/FSH)

29

hypopituitarism in premeopausal see

amenorrhea (decr LH/FSH)

30

hypopituitarism in men see

hypogonadism (decr libido, infertility, impotence)
hypothyroidism
secondary hypocortisolism

31

growth hormone deficiency causes

increased fat mass
decreased lean body mass
decreased bone density
decreased quality of life

32

prolactin deficiency causes

inability to lactate following pregnancy

33

ACTH deficiency causes

secondary hypocortisolism: hypoglycemis, fatigue, anorexia

34

thyrotropin deficiency -TSH

wt gain, dry brittle hair, hair loss, dry skin, constipation, fatigue, cold intolerance, cognitive complaints

35

dx of hypopituitarism

low or inappropriately normal levels of pituitary hormones in the setting of low target hormone ie: low free T4 and normal TSH

36

initial tests for eval of hypopituitarism

MRI of pituitary
IGF-1,free t4, TSH, am cortisol, ACTH, testosterone, LH, FSH, prolactin
(TSH,LH,FSH may be normal or low in hypopituitarism)

37

common etiology of hypopituitarism

tumors, brain radiation
hemochromatosis, amyloidosis
sheehan syndrome, empty sella symdrome
lymphocytic hypophysitis

38

sheehan syndrome

seen after delivery baby, hypotension during labor causes pituitary necrosis
see: failure of lactation, failure to resume regular menses, and fatigue

39

Empty sell syndrome

decreased pituitary gland volume
10% may have hypopituitarism or increased prolactin

40

lymphocytic hypophysitis

symmetric and homogeneous sellar mass
usually occurs during or after pregnancy
adrenal insufficiency is common

41

treatment of hypopituitarism

** cortisol replacement before thyroid replacement
remember stress cortisol dose if ill, stress, surgery
testosterone replacement in males
estrogen/progesterone in females
GH replacement

42

polyuria, think

central diabetes insipidus
nephrogenic diabetes insipidus
psychogenic polydipsia

43

with central diabetes insipidus see

>50% urine osmolality after vasopressin or desmopressin

44

with psychogenic polydipsia see

hyponatremia

increases urine osmolality after water deprivation

45

50 y/o male with headache, decreased libido, sparse facial hair, lab:decreased testosterone,LH, and FSH. prolactin 2000. MRI large pituitary adenoma with suprasellar extension. visual exam-bitemporal heminopsia. Dx and Tx

macroadenoma

bromocriptine

46

in prior pt, if all same except prolactin 50, what dx and tx?

nonsecreting macroadenoma

TX*** nonsecreting large tumors need surgery!!!

47

same patient but free T4,TSH,am cortisol all decreased, prolactin 2000. Dx & Tx

hypopituitarism
tx: cortisol, thyroid, testosterone if male, bromocriptine

48

30 y/o female,2mm pituitary adenoma on routine MRI. asymptomatic and menses and prolactin levels are normal. what to do next?

Dx: incidentiloma
Tx: measure IGF-1 and prolactin, if normal, recheck lab and MRI in 6 months

49

54 y/o male severe headache,nausea, vomiting, hypotension, altered consciousness. MRI show a hemorrhagic mass in the sella.
Dx & Tx

Pituitary Apoplexy (hemorrhage into tumor)

Tx hydrocortisone and surgery

50

patient to ER after head injury. he is polyuric, elevated BUN, Na 150, urine osmolality of 40.
Dx and how to confirm

central diabetes insipitis

IV desmopressine- should decrease urine volume

51

38 y/o female with diabetes, amenorrhea, and bronze pigmentation of skin. Lab: neg pregnancy, decreased FT4,TSH,FSH,LH.
Dx and what to do next

dx: hemochromatosis
do iron studies
replace her hormones and thyroid

52

24 y/o female with polyuria and polydipsia, urine osm is 60 and does NOT change with water deprivation. after vasopressin, osmolality increases to 100. Dx?

central diabetes insipidus

53

19 y/o female with syncope and has K+ 2.5, HCO3 34, urine K 8
Dx?

dx-bulemia
** #1 cause of metabolic alkalosis in young female- vomiting caues lose of acid from the GI tract

54

same 19 y/o patient but HCO3 of 20
whats dx now/

laxative abuse, mild acidosis

55

same 19 y/o but K+ 2.5 and urine K 50
whats diagnosis

diuretic abuse or Barter syndrome (lose K in urine)

56

most common cause of diabetes insipidus

autoimmune

57

patient with polyuria and sodium 128, likely cause

psychogenic polydipsia

58

a few days post op a patient develops Na+ 120. why

pain increases ADH
also use of hypotonic fluids

59

patient on lithium presents with polyuria
urine osm 50, Na+145
Dx & Tx

lithium induced DI
tx-thiazide or amiloride
** do not stop lithium

60

patient with thyrotoxicosis and enlarged thyroid
increased: FT4, T3,TSH,RAI
what next

pituitary tumor-do MRI

(TSH should be decreased with thyrotoxicosis but since it is increased pituitary is the problem)

61

pt w hashimoto for many yrs now has rapidly enlarging neck mass, engorged neck veins,, hoarseness, dysphagia. ultrasound shows enlarged thyroid and cervical glands. Dx

Primary thyroid lymphoma

high incidence with hashimoto's

62

disorders associated with increased risk of thrombosis

prothrombin 20210 mutation
ATIII deficiency
Protein C deficiency
antiphospholipid syndrome
resistance to activated protein C

63

T3 produced by

TSH in pituitary or conversion of T4->T3

64

conditions that impair peripheral conversion of T4 to T3

systemic illness
malnutrition
old age
drugs:propranolol, PTU, iodine contrast

65

with impaired conversion of T4 to T3, see

increased rT3

66

low T3

not used in dx hypothyroidism

low T3 doe not always indicate hypothyroidism
no role in eval of hypothyroidism, so dont measure total T3

67

only time free T3 us ckecked is eval for

thyroitoxicosis

68

labs with thyrotoxicosis (hyperthyroid)

^Total T3 &T4, ^ free T3 & T4
decreased TSH
RAI uptake >30%
^except on thyrotoxicosis factitia

69

hypothyroidism lab

decreased T4 & T3, total and free levels, increased TSH

70

TPO Ab -thyroid peroxidase antibodies and thyroglobulin antibodies seen in

hashimoto thyroiditis

*presence in euthyroid or subclinical hypothyroidism confer an increased risk of developing overt hypothyroidism

71

thyroid stimulating immunoglobulin (TSI) seen in

Graves' disease

72

TSH binding inhibitor immunoglobulin (TBII)

Graves' disease or Hashimoto's thyroiditis

73

a patient with thyrotoxicosis with enlarged thyroid, incr free T4 and free T3, ^TSH, ^RAI. what test to do next?

do pituitary MRI-pituitary tumor

74

pt with hashimoto thyroiditis for years presents with rapidly enlg neck mass, engorged neck veins, hoarse, dysphagia.Likely dx

primary thyroid lymphoma-high incident with hashimotos

75

thyroid binding globulin increased in

pregnancy
estrogen,tamoxifen,methadone
genetic
hepatitis, biliary cirrhosis

76

thyroid binding globulin decreased in

androgens, glucocorticoids
nephrotic syndr, chronic liver disease
severe systemic illness
acromegaly
genetic

77

if suspect thyroid dx, measure

TSH , Free T4

78

high FT4

hyperthyroidism

79

high FT4 and TSH low

primary hyperthyroidism
test RAI uptake

80

RAI uptake with diffuse increase

Graves' disease

81

RAI uptake with focal increase

toxic adenoma

82

RAI uptake with decreased uptake

subacute or lymphocytic thyroiditis
factitious thyrotoxicosis
iodine excess
struma ovarii-teratoma produces thyroid hormone

83

High FT4 and TSH normal or elevated

secondary hypothyroidism-rare-can be due to:
TSH producing tumor
thyroid hormone resistance syndrome

84

Low FT4

hypothyroidism

85

low FT4 and TSH elevated

primary hypothyroidism, check TPO Ab:
(+) Hashimoto
(-) other causes

86

FT4 low and TSH normal or low

secondary hypothyroidism.
get CT,MRI, measure other hormones

87

sick euthyroid syndrome

acute systemic illness can affect thyroid function

88

apathetic thyrotoxicosis

FT4 normal TSH decreased: see apathy rather than hyperacitvity:
lethargy, depression, wt gain, droopy eyelids, constipation . A fib, CHF

89

types of thyroiditis

Hashimoto
painless postpartum, sporadic, subacute
suppurative
drug induced
Riedels

90

hashimoto thyroiditis

#1 cause of hypothyroidism
thyroid firm, lumpy, painless
+ TPO or thyroglobulin antibodies

91

Painless postpartum (lymphocytic) thyroiditis

thyroid enlarged and nontender
thyrotoxicosis at first then hypothyroid, lasts 4-6 months
Tx thyrotoxicosis with beta blockers, hypothyroid with synthroid

92

painful subacute thyroiditis

follows URI,tender and enlarged thyroid, incr sed rate
thyrotoxicosis early->transient hypothyroid->recovery 6-12 month
Tx NSAIDS,steroids if severe pain
B blockers for toxicosis, synthroid for hypothyroid

93

suppurative thyroiditis

fever, chills, tender nodule
tx-drainage and anibiotics

94

drug-induced thyroiditis

amiodarone, lithium, interferon alpha, interleukin 2

95

riedels thyroiditis

rock hard, fixed, painless goiter
negative antibodies
may cause esophageal or tracheal compression

96

indications for RAI (radioactive iodine)

severe hyperthyroidism
very large goiter (>4 x normal)
T3:T4 ratio >20
elevated antithyrotropin antibody

97

contraindications of RAI

pregnant, lactating
unable to comply with safety regulations:
no contact children or pregnant for 1 week
avoid close contact >2 hours at 6 feet or closer for 5 days

98

RAI pretreatment

Bblocker for symptoms
High risk patient tx with antithyroid meds for several weeks prior, stop them 2-3 days before and resume 3-7 days after tx:
elderly, underlying CV dz, severe hyper symptoms,or hormone >2-3 times normal

99

indications for antithyroid drug therapy (PTU,methimazole)

children, preg/lactating
initial tx in adult with severe eye dz, mild-mod hyperthyrodism, small goiter,T3:T4 <20, (-)antithyrotropin antibody
PTU not used as first line except in first trimester pregnancy, and thyroid storm tx

100

antithyroid drug tx for 12-18 months and

if adult relapses->tx with RAI
if child, give second round of antithyroid meds

101

side effects of anti thyroid drugs

agranulocytosis-stop if neutrophil count <1000
arthralgias, polyarthritis
ANCA + vasculitis, immunoallergic hepatitis (PTU)
severe hepatic necrosis)PTU),cholestasis (methimazole)
hypoglycemia-insulin autoimmune syndr (methimazole)

102

Thyroid storm

rare, life threatening condition with severe clinical manifestations of thyrotoxicosis
mortality 15-20%

103

clinical features of thyroid storm

hyperpyrexia
CNS:agitation, delirium,confusion, psychosis, sz, stupor, coma
GI: N/V, diarrhea, abd pain, jaundice
CVS: tachycardia, heart failure, atrial fib

104

causes of thyroid storm

graves dz #1
toxic adenoma
multinodular goiter

105

precipitating factors of thyroid storm

surgery, infection, trauma, parturition, acute iodine exposure, RAI therapy, ingestion of salicylates and pseudoephedrine

106

treatment of thyroid storm

large doses of PTU and SSKI (start 1 hour after PTU) plus propranolol to control heartrate, plus IV hydrocortisone

107

features of Graves opthalmopathy, moderate to severe

spont. retrobulbar pain, pain w eye movement, redness of eyelids, conjuncitva, swelling of eyelids, caruncle and conjunctival edema
eyelid retraction >2mm,exopth>3mm, mod to severe soft tissue involvement, extraocular muscle involvement (diplopia), moderate corneal involvement

108

tx of mod-severe graves opthalmopathy

weekly infusion methylprednisone 500mg X 6 weeks then 250mg weekly for 6 weeks. if no improvement in 3-4 months, give 2nd course of IV steroids with orbital radiation

109

rare manifestations of hypothyroidism

pericardial effusion, CHF, sinus brady, prolong QT, torsades
hypoventilation
increased CPK and +MB fraction
hyperprolactinemia
diffuse pituitary enlargement

110

clinical features of myxedema coma

decr LOC,psychosis, seizures
Hypothermia, hypoventilation leading to hypoxia and incr PCO2
hyponatremia, hypotension, hypoglycemia
sinus bradycardia

111

must rule this out in any patient with coma and has low heartrate

myxedema coma

112

precipitating factors in myxedema coma

cold weather
sedatives
infections

113

tx of myxedema coma

high doses of both levothyroxine and glucocorticoid

114

multinodular goiter with normal FT4,normal TSH

observe

115

multinodular goiter with normal FT4 and low TSH, treatment

symptomatic-RAI

asymptomatic-observe

116

multinodular goiter with increased FT4 and Low TSH Tx

RAI

117

Jod-Basedow phenomenon

patient with multinodular goiter that develop thyrotoxicosis on exposure to iodine containing contrast agents

118

tx of papillary and follicular thyroid carcinoma

near total thyroidectomy
RAI after 6 weeks when TSh >50-ablates thyroid remnants/mets
thyroid hormone replacement
repeat scan 6-12 month
follow serial thyroglobulin levels, repeat scan if increase levels

119

indications of RAI tx after thyroidectomy for cancer

all with distant mets
extrathyroidal extension of tumor regardless of size
primary tumor >4cm even with no high risk features
1-4cm w lymph node mets or high risk features

120

thyroid nodules with high suspicion of thyroid cancer

nodule firm/hard/fixed to adjacent structures
rapid growth
regional or distant lymphadenopathy
paralysis of vocal cords
family Hx medullary ca or MEN syndrome

121

thyroid nodules with moderate suspicion of thyroid Cancer

male, age 70
hx of head and neck radiation
dysphagia, hoarse, dyspnea, cough
U/S: >3cm, speckled calcification w/in nodule, high vasc flow in center, hypoechogenicity,irreg border, taller than wide

122

thyroid nodules indications for biopsy

nodule >1cm or smaller if risk factors
if nodule >3cm and FNA is (-), consider repeat

123

effects of amiodarone on thyroid functions

hypothyroidism--dont stop drug, tx with synthroid
hyperthyroid in pt w prior graves or multinodular goiter-discontinue amiodarone, may need antithyroid meds
impaired T4 to T3 conversion

124

intensive therapy to achieve near-normal glucose delays onset and slows the progression of

microvascular complications of diabetes (retinopathy,nephropathy,neuropathy). but NOT the macrovascular complications (MI, CVA)

125

microalbuminuria - 30-300mg/gm of cr on random urine sample

risks: increase risk of overt renal failure and CAD

Tx: control BP <130/80, ACE/ARB
intense bs control

126

types of diabetes

Type I
Type II
genetic defects
secondary causes

127

type I diabetes is

autoimmune destruction of pancreatic beta cells, insulin deficiency, ketosis prone, positive islet cell or glutamic acid decarboxylate antibody

128

type II diabetes is

impaired insulin secretion
increased insulin resistance
excessive hepatic glucose production

129

genetic defect as cause of diabetes

MODY-maturity onset diabetes of the young

130

secondary causes of diabetes

chronic pancreatitis, CF, hemochromatosis, acromegaly, cushings,pheochromocytoma,hyperthyroidism, gestational
Crugs: niacin, glucocorticoids, thiazides, protease inhibitors, clozapine, cyclosporine

131

diagnosis of DM

symptoms + random blood glucose >/= 200
2 hr glucose >/=200 after 75gm glucose tol test
8 hr fasting plasma glucose >/= 126 on 2 occasions
HgbA1c >/= 6.5

132

prediabetes

fasting plasma glucose 100-125
2 hour plasma glucose 140-199 after 75gm glucose
HgbA1c 5.7-6.4

133

what is risk of coronary event in pt with diabetes?

same as those with KNOWN CAD

134

patient with Type I DM has acute pancreatitis. BS 500, TG 5000. what is best tx of the TG in this patient?

IV insulin

135

54y/o with FBS 115, 2 hr glucose TT 130, HgbA1c 6, BMI 36.
DX and TX

prediabetes
diet and exercise

136

how to differentiate T.I and T.II diabetes?

(+) GAB antibodies in Type I

137

where should you maintain blood glucose in critically ill patient?

140-180

138

preferred initial agent in diabetic if no contraindication

metformin

139

actions of metformin

decrease glucose production in the liverr
increase uptake & util. of glucose by adipose ad muscle
no effect on insulin release
promotes wt loss and lowers lipids
decreases macrovasc. complications (MI,CVA)

140

metformin toxicity

lactic acidosis
metalic taste
nausea
diarrhea
abdominal pain

141

contraindications of metformin

renal dz:male cr >1.5, female >1.4, GFR <60
impaired liver function, chronic alcoholism or binge drinking
CHF
severe hypoxia

142

discontinue/hold metformin

prior to radiographic contrast material
prior to surgery or in critically ill patients
if pt develops N/V

143

rapid acting insulin

humalog-insulin lispro
novolog-aspart
apidra-glulisine
inhaled insulin

144

short acting insulin

regular-given 30 min before meal

145

intermediate acting

NPH
Lente

146

long acting insulin

lantus-once a day-insulin glargine
detemir-given BID

147

premixed insulin

NPH/regular- 70/30, 50/50
protamine aspart/aspart 70/30
protamine lispro/lispro 75/25, 50/50

148

management type 2 DM-lifestyle intervention and metformin, if HbA1c > or = 7% do one of below

add basal insulin-most effective
add sulfonylurea-least expensive, add below if not controlled
add glitazone-avoid hypoglycemia-add sulfonyl if still not control then basal insulin etc.

149

insulin tx in type 2 DM:hs NPH or daily lantus (10units or 0.2u/kg starting dose)->FBS daily, inc dose by 2units every 3 days (4 units if FBS.180)until target range 70-130. after 3 mo if HbA1c.=or > 7%, FBS ac and hs.

if glucose incr still, add rapid acting insulin:
pre lunch bs incr-add insulin before breakfast
pre dinner incr bs- add insulin before lunch
if incr at hs-add insulin before dinner

150

goals for tx of diabetes

HbA1c 40 in male, >50 female,TG50,female>60

151

insulin dosing

total dose .2-0.4 unit/kg/d one-half dose as basal insulin, other half give rapid acting (humalog, novolog) divided equally before each meal

152

ideally prandial insulin is determinedby amount of carbs about to be consumed ( 1 unit for 10-15gm carb) plus a correction factor predicated on preprandial glucose ( 1 extra unit for every 40-50mg/dl above 100)

see above

153

diabetic ketoacidosis

insulin deficiency and glucagon excess
incr gluconeogenesis & decr peripheral glucose utilization
release of fatty acids from adipose tissue
accelerated fatty acid oxidation in the liver
incr ketones (beta hydroxybutyrate/acetoacetic acid)

154

precipitating factors of diabetic ketoacidosis

inadequate insulin administration
infection,MI,CVA
surgery, trauma
pregnancy
cocaine

155

clinical features of diabetic ketoacidosis:
anorexia, N/V, polyuria, polydipsia
altered mental status,focal deficits, coma , Kussmaul respiraions, acetone odor on breath, diffuse abd pain
tachycardia, hypotension, dehydration

Lab: increased WBC,TG,amylase
decreased sodium (1.6 meq decr for each 100 rise in serum glucose) decreased HCO3, decr K+.
+ ketones

156

Tx of DKA
1. severe hypovolemia-normal saline at 1 liter/hour
mild dehydration-correct Na: high-0.45% Nacl 250-500ml/h.when serum glucose

2. insulin-regular 0.1 u/kg IV bolus then 0.1u/kg/hr IV continuous infusion until glucose 200, decrease insulin to 0.05-0.1u/kg/h to maintain glucose 150-200.
3.potassium-,3.3-hold insulin, give K 40-0meq/hr until K .3.3, if K+ is 3.3-3.5-repl K at 10meq/hr, if K+>5.3 hold K
4. HCO3-given only if pH ,7.0or HCO3

157

complications during tx of DKA

accelerated coagulopathy
cerebral edema- more common kids, progressive neuro deterioration-IV mannitol
hyperchloreic acidosis, hypophosphatemia(rhabdo, cardiomyopathy,hemolytic anemia), hypoglycemia, hypokalemia

158

in noncritical inpatients, goal fasting glucose

90-140 and random or postprandial levels 150 (graded scale 1-4 units for each 50 mg/dl

159

autonomic neuropathies in diabetes

gastroparesis, alternating diarrhea and constipation, impotence, urinary incontinence or retention, orthostatic hypotension without reflex tachycardia, persistent sinus tachycardia

160

gastroparesis in diabetes symptoms

early saiety
N/V
dyspepsia
postprandial abd fullness

161

Dx gastroparesis in diabetes and tx

Dx-gastric emptying scan
Tx-metoclopramide or erythromycin

162

risk factors for diabetic foot ulcers

increased formation of keratin
loss of pressure sensation
loss of pain and temperature sensation
weakness of intrinsic muscles
loss of sweating

163

clinical features of hyperglycemic hyperosmolar state

profound dehydration, hypotension, incr HR, alt mental status
NO-N/V,abd pain, Kussmauls are NOT present
often precipitated by serious illness:MI,CVA,sepsis, pneumonia

164

labs in hyperglycemic hyperosmolar state

marked hyperglycemia (600-1200)
hyperosmolality (330-380)
Na+ normal to mild decr-correct add 1.6 meq to measured Na for every 100mg rise in glucose
small anion gap acidosis due to lactic acidosis, serum ketones +/-

165

Tx hyperglycemic hyperosmolar state

NS initially and change to 1/2 NS after hemodyn. stable. water deficit is 9-10 liters and should be replaced over 2-3 days.
insulin bolus 0.1 unit/kg then drip 0.1unit/kg/hr
when glucose 200-300 add D5 and reduce insulinto 0.05-0.1unit/kg

166

manifestations of vit D deficiency

osteomalacia, ricketts in children, osteopenia/osteoporosis
muscle weakness and incr risk of falls
incr risk of: cancer(breast,colon,prostate), HTN, CV dz,diabetes, metabolic syndr, MS, schizophrenia, depression

167

Osteomalacia-manifestation of vit D deficiency see

bone pains/tenderness, fracture after minimal trauma, pseudofractures
Lab: calcium-normal or decreased
phosphorous-normal to decreased
increased alk phos

168

vitamin D testing

measure 25(OH)D2 and D3
normal 30-60
<20 tx 50,000u D2 weekly for 6- weeks then 800u/d of D3
20-30 tx vit D3 800u/d

169

causes of vit D deficiency

reduced skin synthesis-decr sun exposure, sunscreens,skin pigmentation,aging
decreased bioavailability-malabsorption, obesity
increased catabolism-anticonvulsants, glucocorticoids, HAART
breastfeeding, pregnancy, lactation

170

cont causes of vit D deficiency

decr synthesis of 25(OH)D-liver disease
incr urinary loss of 25(OH)D-nephrotic syndrome
decr synthesis of 1-25(OH)2-chronic kidney disease
tumor induced osteomalacia-phosphaturia
primary hyperparathyroidism-decr 25(OH)D, incr 25(OH)2D

171

cont causes of vit D deficiency

granulomatous diseases-decr 25(OH)D incr 1-25(OH)2D
thyrotoxicosis-incr metabolism of 25(OH)D
heritable disorders-ricketts

172

hypercalcemia with high or normal PTH

hyperparathyroidism
lithium
familial hypocalciuric hypercalcemia

173

hypercalcemia with lor or undetected PTH-

if chronic:sarcoid,thyrotoxicosis, adrenal insuff., immobilization, drugs(thiazides, vit A&D, calcium carbonate.
if acute:MALIGNANCY-if incr Ca, decr P-humoral
-if incr Ca, P normal-metastatic myeloma

174

Multiple endocrine neoplasia

MEN1, MEN IIa, MEN IIb

175

MEN I

hyperparathyroidism
pituitary
pancreatic tumors

176

MEN IIa

hyperparathyroidism
pheochromocytoma
medullary carcinoma

177

MEN IIb

pheochromocytoma
medullary carcinoma
mucosal neuromas
marfanoid habitus

178

familial hypocalciuric hypercalcemia

autosomal dominant
decr calcium excretion<0.1
parathyroidectomy DOES NOT correct calcium

179

hyperparathyroidism-indications for surgery

age 400,hx life threat hypercalcemia
symptomatic hypercalcemia
renal stones , Ca >1 above normal , decr bone mass (T score<60

180

hyperparathyroidism procedures

sestamibi parathyroid scanning (best),neck ultrasound
indicated if minimally invasive surgery is planned

181

hyperparathyroidism-medical treatment

avoid thiazides, normal calcium intake, maint 25(OH)D>20
bisphosphonates if low bone mass
Cinacalcet(calcimimetic agent) use in symptomatic pt not surgical candidates
monitor calcium and cratinine annually and bone density 1-2 years

182

hypercalcemia of malignancy

humoral
metastatic
osteoclast activating factors
ectopic PTH secretion (rare)
coexisting primary hyperparathyroidism

183

hypercalcemia of malignancy-humoral

PTHrP increased Ca, decreased P
squamous cell ca of the lung and other sites
other tumors:renal, breast, ovary, endometrium

184

hypercalcemia of malignancy-metastatic

breast
prostate
thyroid
lung
kidney

185

hypercalcemia of malignancy-osteoclast activating factors

interleukin-1
TNF
1-25(OH)2 vit D

186

tx of hypercalcemia

hydrate with NS, loop diuretics, phosphate repletion if P <3.0
Meds: first line-IV bisphosphonates (Pamidronate, Zoledronate)
2nd line-glucocortioids, Mithramycin,calcitonin, gallium nitrate

187

Hypoparathyroidism

diseases assoc with: addisons, premature ovarian failure, autoimmune thyroid disease, pernicious anemia, mucocutaneous candidiasis
LAB: decr Ca++.decr PTH, incr P

188

hypocalcemia

PTH absent (decr Ca++,decr PTH, incr P)-hypoparathyroidism, hypomagnesenia (leads to decr Ca++, decr K)
PTH ineffective (decr Ca++,incr P & PTH)-end organ resistance to PTH-short 4th and 5th metacarpals and metatarsals
PTH overwhelmed-severe acute hyperphosphatemia(tumor lysis, rhabdomyolysis, ARF, hungry bone syndrome(after surgery for hyperparathyroidism)

189

tx of hypocalcemia

oral calcium and Vit D to keep calcium 8-8.5
IV calcium gluconate for acute symptomatic hypocalcemia